where can you buy the abortion pill

There he could simply order medical abortion pill online generic.There we could simply order generic cytotec abortion. Secure mifepristone and misoprostol every twelve hours tablets.

cheapest biaxin

order clarithromycin 500mg buy clarithromycin buy biaxin australia

purchase biaxin

buy clarithromycin 500mg buy clarithromycin pills purchase clarithromycin

cheap biaxin

buy biaxin uk buy clarithromycin buy biaxin pills

buy discount clarithromycin

buy biaxin 250mg buy clarithromycin usa cheapest biaxin

purchase clarithromycin

purchase biaxin purchase clarithromycin buy biaxin no prescription

generic clarithromycin

clarithromycin online buy clarithromycin buy clarithromycin australia

order clarithromycin

clarithromycin reviews buy clarithromycin biaxin reviews

order clarithromycin 500mg

order clarithromycin buy biaxin australia buy clarithromycin online

cheapest clarithromycin

purchase clarithromycin http://www.geospatialworld.net/Event/View.aspx?EID=63#buyclarithromycin buy clarithromycin

buy cytotec for 24 week abortion

pill for abortion online abortion pill buy the abortion pill online

i need to buy the abortion pill

ordering abortion pills to be shipped to house http://www.cengage.co.in/content/privacy-statement order abortion pill

medical abortion pill online

abortion pill online ordering abortion pills to be shipped to house cytotec abortion

cytotec abortion pill buy online

order abortion pill online http://www.geospatialworld.net/Event/View.aspx?EID=53 i need to buy the abortion pill

abortion pill online purchase

abortion pill prescription abortion pill buy abortion pills online

women does viagra work

viagra reviews viagra pharmacy cheap viagra tablets

cialis vs kamagra

alternative to kamagra cheap kamagra kamagra canada

kamagra jelly jokes

buy kamagra jelly online safe mail order kamagra jelly kamagra jelly jokes

cialis vs amoxicillin

get amoxil http://www.cengage.co.in/content/academic-professional amoxil equivalent

buy cheap thyroxine online uk

synthroid prescription synthroid women does synthroid work

get discount laxative online

free bisacodyl sample http://www.cengage.co.in/content/library-reference get discount bisacodyl online

fedex generic principen

buy ampicillin online principen without prescription natural principen alternatives

how to order the abortion pill online

buy abortion pills online where can i buy abortion pills cytotec abortion

cheapest biaxin

buy cheap biaxin http://www3.umu.se/kultmed/kurswebb/default.aspx?id=29 order clarithromycin 250mg

natural cipro

buy cipro online ciprofloxacin buy ciprofloxacin online a href

fedex generic clindamycin

mail order clindamycin clindamycin photos clindamycin

dexamethasone equivalent

buy dexamethasone online http://www.geospatialworld.net/Event/View.aspx?EID=44 buy dexamethasone online a href

female herbal Cefadroxil

female herbal duricef fedex generic Cefadroxil Cefadroxil prescription buy

generic cefpodoxime online

how does vantin work buy vantin online mail order cefpodoxime

free ceftin sample

buy cefuroxime online a href cefuroxime prescription buy ceftin prescription

where can you buy the abortion pill

how to order the abortion pill online where can i buy abortion pills on line abortion pill

how does cephalexin work

purchase cephalexin online free keflex sample get cephalexin avoid prescription

female herbal chloromycetin

buy chloromycetin las vegas chloromycetin for sale chloromycetin prescription

cytotec abortion

buy the abortion pill online buy cytotec for 24 week abortion abortion pill prescription

female herbal augmentin

purchase clavulanate online generic clavulanate how does clavulanate work
 About the Journal
 Editorial Board
Subscribe to E- Alerts
Contact Us
Hitzplus Jokes, Wallpapers, Bollywood, Videos and e-cards | Bollywood News, Reviews, Songs, Hindi Bollywood Movies
 
Article Options
FULL TEXT
ABSTRACT
PDF
Printer Friendly Version
Search Pubmed for
Search Google Scholar for
Article Statistics
Bookmark and Share
Case Report
 
Recurrent paralytic ileus..... could be Gitelman’s syndrome!

RV Dosi, A Ambaliya, RD Patell, RS Patil, PJ Shah

Department of Medicine, Government Medical College & S.S.G. Hospital, Vadodara, Gujarat, India.



Corresponding Author
:

Dr. Rupal Dosi

74-B, Kunj society, Alkapuri, Vadodara-390007, Gujarat, India.
E-mail: rupal265@yahoo.com



History : Received - 08-May-2012 Accepted - 20-Oct-2012 Published Online -  24-Oct-2012
DOI : http://dx.doi.org/10.7713/ijms.2012.0062


Abstract

Gitelman’s syndrome is a type of hereditary tubular disorder, although a relatively frequent cause of chronic hypokalaemia in adults, but is rarely diagnosed correctly. We describe a case of a 51 year old man with a 15 month history of recurrent paralytic ileus attributed to recurrent hypokalaemia. Investigations in this patient revealed hypokalaemia, metabolic alkalosis, hypocalciuria, and hypomagnesaemia, a tetrad diagnostic of Gitelman’s syndrome. The peculiar clinical features of this condition and its management are discussed.

Keywords : Alkalolis; Bartter syndrome; calcium metabolism disorders; differential diagnosis; diuretics; hypokalemia; hypomagnesemia.

Introduction

Gitelman’s syndrome, also known as ‘hypocalciuric variant of Bartter’s syndrome’, is a relatively frequent cause of chronic hypokalaemia and hypomagnesaemia in adults. Nevertheless, there are few reports on this inherited disorder as a cause of hypokalaemia. This diagnostic possibility is not customarily considered as many of the pathophysiological manifestations of Gitelman’s syndrome are mimicked by the administration of thiazide diuretics [1,2].

Report of case

A 51 year old man presented with persistent vomiting and abdominal distension since last 3 days. Patient had similar history of distension of abdomen 15 months and 3 months ago. During both the previous episodes, patient had severe hypokalaemia. Patient had been diagnosed as a case of paralytic ileus due to hypokalaemia but had not been further investigated. Describing the present illness, he had persistent vomiting for 3 days, which was followed by abdominal distension. He had not had loose motions, had not been on diuretic therapy and was neither hypertensive nor diabetic. He was not born out of a consanguineous marriage.

Examination revealed a conscious, oriented patient with signs of dehydration, pulse rate of 100/min and blood pressure 100/70 mm Hg. While measuring blood pressure he had carpal spasm (positive Trousseau’s sign- Figure 1).



Abdominal examination showed distended bowel loops and absent bowel sounds. Cardiovascular, respiratory and central nervous system examinations were normal.

On investigation, complete blood counts, random plasma glucose and urine examination (routine as well as microscopic) were normal. Chest X-ray was normal but abdominal X-ray showed distended bowel loops with multiple air-fluid levels. Abdominal sonography also revealed distended bowel loops, but no other abnormality. ECG was suggestive of ST depression with T wave flattening in V1-V4, I, aVL.

Arterial blood gas analysis revealed pH 7.56, PaCO2- 38.1 mm Hg, PaO2- 66.5 mm Hg, SpO2- 92.2%, bicarbonate of 34.4 meq/L, chloride of 102 meq/L; suggestive of non-compensated metabolic alkalosis. Serum calcium (6.5 mg/dL; normal- 8.5-11 mg/dL) and serum magnesium levels (1.4 mg/dL; normal 1.6-2.3 mg/dL) were low. Urinary chloride levels were 105 meq/L (normal value is < 20 meq/L) and urinary potassium levels were 25.2 meq/day (normal value is < 15 meq/day). However, 24-hour urinary calcium excretion was reduced at 91 mg/dL (normal range 100-300 mg/dL). Urine calcium to creatinine ratio was 0.09 (normal value < 0.15). High urinary potassium and urinary chloride levels are suggestive of renal loss of potassium and chloride.

A diagnosis of Gitelman’s syndrome contributing to hypokalemia and paralytic ileus was entertained.

Discussion

This normotensive patient presented with recurrent hypokalaemia leading to frequent paralytic ileus and metabolic alkalosis. Investigations revealed that the patient was losing potassium in urine. The differential diagnoses for metabolic alkalosis with hypokalaemia with a normal blood pressure, as was seen in this patient could be- Gitelman’s syndrome or Bartter’s syndrome.

Although measuring levels of aldosterone and renin were not possible due to financial constraints, hyperaldosteronism appeared unlikely in view of persistently normal blood pressure. The patient may have had a secondary cause of hypokalaemia because of persistent vomiting, which was excluded on the basis of the high 24 hour chloride excretion. The patient had hypomagnesaemia and hypocalciuria with urinary calcium to creatinine ratio was < 0.15; and so the final diagnosis was Gitelman’s syndrome.
Hypocalciuria reliably differentiates Gitelman’s syndrome from Bartter’s syndrome, although hypomagnesaemia can be seen in 30% of Bartter’s syndrome [3].

Gitelman’s syndrome is a much more common disease than Bartter’s syndrome. Prevalence is approximately 1 per 40,000. Moreover, the prevalence of heterozygotes may be as high as 1 percent. The locus of mutation in Gitelman’s syndrome is present on chromosome 16q13(SLCA3). Gitelman’s syndrome is an autosomal recessive disorder with 99% penetrance. To date, about 50 distinct mutations have been found. Severe hypokalaemia in adults is more likely to be due to Gitelman’s syndrome than Bartter’s syndrome. Only 7% of sodium chloride is normally reabsorbed in the distal convoluted tubule, in contrast to 25% in the thick ascending limb. Consequently, the symptoms due to volume depletion are milder in Gitelman’s syndrome than in Bartter’s syndrome. Analogous to the use of thiazides, prostaglandinuria is absent in Gitelman’s syndrome and the aldosterone concentration is often only mildly elevated because hypokalaemia suppresses adrenal aldosterone production [4,5]. In contrast to Bartter’s syndrome, Gitelman’s syndrome is a mild disease. These patients are not volume depleted clinically, and polyuria and polydipsia are absent because the urinary concentration ability is intact or only slightly impaired. Adults with Gitelman’s syndrome are often detected by chance because of routine electrolyte measurements, or they present with musculoskeletal symptoms such as generalised muscle weakness and fatigue. Affected patients sometimes have a history of episodes of tetany, carpopedal spasms or seizures. This typically occurs when the serum magnesium is further decreasing, e.g. during episodes of vomiting, diarrhoea or fever. Nevertheless, hypocalcaemia is seen in up to one third of hypomagnesaemic patients and is explained by impaired release of PTH and/or resistance to its peripheral action. The differences between Bartter’s and Gitelman’s syndromes are outlined in table 1.



Gitelman’s syndrome usually presents in late childhood or adult age, but our patient presented at around 50 years with recurrent paralytic ileus. Such a presentation is uncommonly reported [6]. He had severe hypokalaemia, metabolic alkalosis, hypocalciuria, and hypomagnesaemia; a classical tetrad of Gitelman’s syndrome.

The patient was treated with intravenous potassium chloride supplementation 20 mEq/hour, through a peripheral line and tablet spironolactone 25 mg three times daily. He was put on oral supplements i.e. potassium citrate and magnesium citrate tablet. Serum potassium rose to 4.2 mEq/L from initial value of 1.7 mEq/ L. He is on continuous potassium and magnesium supplements and need for life-long compliance has been explained to him.

Key Points

• Gitelman’s syndrome is characterised bytetrad of- hypokalaemia, metabolic alkalosis, hypomagnesemia and hypocalcaemia.
• A case of Gitelman’s syndrome presenting with recurrent paralytic ileus due to chronic hypokalaemia is being reported.
• Gitelman’s syndrome is a common cause of hypokalaemia, but often goes unrecognised.

References

1. Singh NP, Kaur G, Prakash A. Inherited salt-losing renal tubulopathies manifesting as normotensive hypokalemic metabolic alkalosis. J Assoc Physicians India 2010;58:283-4.[PUBMED]
2. Knoers NV, Levtchenko EN. Gitelman syndrome. Orphanet J Rare Dis 2008;3:22.[PUBMED]
3. Guay-Woodford LM. Bartter syndrome: unravelling the pathophysiologic enigma. Am J Med 1998;105:151-61.[PUBMED]
4. Luthy C, Bettinelli A, Iselin S, Metta MG, Basilico E, Oetliker OH, et al. Normal prostaglandinuria E2 in Gitelman’s syndrome, the hypocalciuric variant of Bartter’s syndrome. Am J Kidney Dis 1995;25:824-8.[PUBMED]
5. Kurtz I. Molecular pathogenesis of Bartter’s and Gitelman’s syndromes. Kidney Int 1998;54:1396-410. [PUBMED]
6. Sundar U, Lakkas Y, Asole D, Vaidya M. Gitelman’s syndrome presenting as recurrent paralytic ileus due to chronic renal tubular K+ wasting. J Assoc Physicians India 2010;58:322–4.[PUBMED]

buy clarithromycin usa

purchasing clarithromycin buy clarithromycin buy clarithromycin pills

biaxin buy

order clarithromycin 250mg cheapest clarithromycin buy cheap biaxin

order clarithromycin

buying clarithromycin buy clarithromycin buy biaxin australia

buy clarithromycin 250mg

clarithromycin online http://www.geospatialworld.net/Event/View.aspx?EID=63#buyclarithromycin ordering clarithromycin

buy biaxin online

buy biaxin pills buy clarithromycin order clarithromycin

buy generic biaxin

buy clarithromycin http://www.geospatialworld.net/Event/View.aspx?EID=53 generic biaxin

buy biaxin 250mg

buy generic biaxin buy biaxin 500mg ordering biaxin

cheapest biaxin

clarithromycin buy clarithromycin biaxin buy

buy generic clarithromycin

buy biaxin canada order biaxin tablets clarithromycin reviews

on line abortion pill

online purchase abortion pill abortion pill abortion pills online

how to order the abortion pill online

buy abortion pill online http://www.cengage.co.in/content/privacy-statement buy abortion pill

abortion pills online

where to buy abortion pill abortion pill on line abortion pill

buy abortion pills online

how to order the abortion pill online where can i buy abortion pills order abortion pill

cytotec abortion

abortion pill buy online abortion pill buy the abortion pill online

buy viagra online inurl:nc

discount viagra viagra online female viagra

generic for kamagra

buy kamagra in great britain kamagra buy kamagra in london england

get kamagra jelly online

how does kamagra jelly work where to buy kamagra jelly online female free sample kamagra jelly

buy cheap amoxil

female free sample amoxil amoxicillin online uk photos amoxil

thyroxine samples

thyroxine samples synthroid women does thyroxine work

generic bisacodyl

bisacodyl samples laxative generic bisacodyl online

free ampicillin sample

where to buy principen online ampicillin how to use ampicillin

buy abortion pill

where can i get the abortion pill online abortion pill abortion pills

buy clarithromycin uk

buy biaxin http://www3.umu.se/kultmed/kurswebb/default.aspx?id=29 discount clarithromycin

fedex generic cipro

buy ciprofloxacin online http://www.geospatialworld.net/Event/View.aspx?EID=37 mail order ciprofloxacin

clindamycin online

buy cleocin on the internet http://www.geospatialworld.net/Event/View.aspx?EID=62 buy cleocin online

mail order dexone

photos dexamethasone generic dexone how does dexone work

buy Cefadroxil las vegas

natural Cefadroxil alternatives cefadroxil buy Cefadroxil

get cefpodoxime

vantin uk buy vantin get vantin online

cefuroxime online shop in uk

alternative to ceftin get discount cefuroxime online cheap cefuroxime

where to buy abortion pill

on line abortion pill abortion pill buy abortion pill online

get keflex online

cephalexin dosage generic keflex buy keflex on the internet

buy cheap chloromycetin online uk

get chloramphenicol http://www.fareastjournals.com/conf_detail.aspx?conf_id=6 photos chloramphenicol

order abortion pill online

abortion pill buy online http://www.fareastjournals.com/journal_detail.aspx?jid=18 buy abortion pill

clavulanate prescription

augmentin dosage augmentin how to use augmentin


cheapest biaxin

order clarithromycin 500mg buy clarithromycin buy biaxin australia

purchase biaxin

buy clarithromycin 500mg buy clarithromycin purchase clarithromycin

cheap biaxin

buy biaxin uk clarithromycin reviews buy biaxin pills

buy discount clarithromycin

buy biaxin 250mg buy clarithromycin cheapest biaxin

purchase clarithromycin

purchase biaxin cheap biaxin buy biaxin no prescription

generic clarithromycin

clarithromycin online buy clarithromycin buy clarithromycin australia

order clarithromycin

clarithromycin reviews ordering biaxin biaxin reviews

order clarithromycin 500mg

order clarithromycin buy clarithromycin uk buy clarithromycin online

cheapest clarithromycin

purchase clarithromycin buy clarithromycin buy clarithromycin

buy cytotec for 24 week abortion

pill for abortion online http://www.cengage.co.in/content/about-us buy the abortion pill online

i need to buy the abortion pill

ordering abortion pills to be shipped to house abortion pill order abortion pill

medical abortion pill online

abortion pill online buy cytotec for 24 week abortion cytotec abortion

cytotec abortion pill buy online

order abortion pill online on line abortion pill i need to buy the abortion pill

abortion pill online purchase

abortion pill prescription abortion pill buy abortion pills online

women does viagra work

viagra reviews viagra pharmacy cheap viagra tablets

cialis vs kamagra

alternative to kamagra http://www.cengage.co.in/content/terms-of-use kamagra canada

kamagra jelly jokes

buy kamagra jelly online safe kamagra jelly kamagra jelly jokes

cialis vs amoxicillin

get amoxil amoxicillin amoxil equivalent

buy cheap thyroxine online uk

synthroid prescription synthroid women does synthroid work

get discount laxative online

free bisacodyl sample buy laxative on the internet get discount bisacodyl online

fedex generic principen

buy ampicillin online ampicillin natural principen alternatives

how to order the abortion pill online

buy abortion pills online http://www3.umu.se/kultmed/kurswebb/default.aspx?id=1 cytotec abortion

cheapest biaxin

buy cheap biaxin http://www3.umu.se/kultmed/kurswebb/default.aspx?id=29 order clarithromycin 250mg

natural cipro

buy cipro online http://www.geospatialworld.net/Event/View.aspx?EID=37 buy ciprofloxacin online a href

fedex generic clindamycin

mail order clindamycin clindamycin photos clindamycin

dexamethasone equivalent

buy dexamethasone online free dexamethasone sample buy dexamethasone online a href

female herbal Cefadroxil

female herbal duricef cefadroxil Cefadroxil prescription buy

generic cefpodoxime online

how does vantin work cefpodoxime mail order cefpodoxime

free ceftin sample

buy cefuroxime online a href http://www.geospatialworld.net/Event/View.aspx?EID=154 ceftin prescription

where can you buy the abortion pill

how to order the abortion pill online medical abortion pill online on line abortion pill

how does cephalexin work

purchase cephalexin online free keflex sample get cephalexin avoid prescription

female herbal chloromycetin

buy chloromycetin las vegas chloromycetin for sale chloromycetin prescription

cytotec abortion

buy the abortion pill online http://www.fareastjournals.com/journal_detail.aspx?jid=18 abortion pill prescription

female herbal augmentin

purchase clavulanate online alternative to augmentin how does clavulanate work