Anesth Analg 2006;102:642-643
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000184827.79120.43
GENERAL ARTICLES
Acute Appendicitis in a Patient with Undiagnosed Pheochromocytoma
Nicki S. Tarant, DO,
Rhodel G. Dacanay, MD,
Brian W. Mecklenburg, MD,
Sean D. Birmingham, MD,
Eugenio Lujan, MD, and
Richard Green, MD
Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
Address correspondence to Brian W. Mecklenburg, MD, c/o Clinical Investigation Department (KCA), Naval Medical Center San Diego, 34800 Bob Wilson Drive, Ste. 5, San Diego, CA 92134-1005. Address e-mail to bwmecklenburg{at}nmcsd.med.navy.mil.
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Abstract
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Pheochromocytoma is a rare catecholamine-producing tumor that can cause severe hypertension and other systemic disturbances. A clinical challenge arises when a patient with a previously undiagnosed and untreated pheochromocytoma presents with a surgical emergency. We describe a patient presenting with acute appendicitis in whom surgery was cancelled because of suspected pheochromocytoma. The possibility of mortality associated with surgery in a patient with an undiagnosed pheochromocytoma outweighed the risk of nonoperative management for appendicitis. This case resulted in a nonoperative resolution of appendicitis and an unremarkable recovery once appropriate hypertension treatment was administered.
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Introduction
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Pheochromocytoma is a rare catecholamine-producing tumor that can cause severe hypertension and other systemic disturbances. Progress in the perioperative management of pheochromocytoma has been well described (1). Appropriate preoperative medical management dramatically decreases morbidity and mortality during the operative management of this tumor (2). We describe a patient presenting with acute appendicitis in whom surgery was cancelled because of the anesthesiologist's suspicion of pheochromocytoma.
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Case Report
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A 27-yr-old female patient was brought to the preoperative holding area with acute appendicitis. Her chief complaint included a 3-day history of fever, headache, dizziness, and abdominal pain. Her medical history was significant for untreated hypertension and occasional headache. Review of systems revealed intermittent palpitations without diaphoresis or syncope. Her vital signs included an arterial blood pressure of 186/98 mm Hg and heart rate of 114 bpm. Physical examination was only significant for bilateral lower quadrant tenderness. Laboratory analysis was remarkable for a white blood cell count of 13.5 x 103/mm3. Chest radiographs were remarkable for a tortuous aorta suggestive of systemic hypertension. Computed tomography (CT) of the abdomen without contrast revealed a distal appendicolith and findings suggestive of acute appendicitis without evidence of abscess formation.
Standard monitors were applied and an arterial catheter was inserted to help monitor arterial blood pressure. Vital signs in the operating room revealed an invasive blood pressure of 200/105 mm Hg, heart rate of 120 bpm, and respiratory rate of 16 breaths/min. To return hemodynamic values to normal, fentanyl 100 µg, nitroprusside 160 µg, phentolamine 5 mg, and labetolol 100 mg were given IV. Additionally, esmolol was titrated to 300 µg · kg–1 · min–1 and nitroprusside to 1 µg · kg–1 · min–1. This treatment resulted in a systolic blood pressure of 160 mm Hg and a heart rate of 82 bpm.
With the difficulty in controlling arterial blood pressure and the patient's medical history, the anesthesiologist raised the concern of pheochromocytoma. The anesthesiologist and surgeon agreed that the risk of performing surgery on an uncontrolled pheochromocytoma was greater than the nonoperative management of appendicitis. The patient was transferred to the intensive care unit for further monitoring and treatment of her hypertension. Initially, her hypertension was treated with a nitroprusside infusion, esmolol infusion, and phentolamine 10 mg every 8 h. Her appendicitis was treated with an antibiotic (piperacillin/tazobactam 3.375 gm IV every 6 h).
On hospital day 2, blood cultures revealed Escherichia coli bacteremia. The patient's temperature, abdominal examination, and white blood cell count all normalized. Random urine analysis disclosed metanephrine of 18,578 µg/dL (normal range, 75–465 µg/dL) and normetanephrine of 10,985 µg/dL (normal range, 30–145 µg/dL), confirming the diagnosis of pheochromocytoma. Phenoxybenzamine was titrated to control her arterial blood pressure. Follow-up CT of the abdomen and pelvis revealed findings suggestive of acute appendicitis, despite marked clinical improvement. The patient was discharged to home on hospital day 9. The patient's abdominal signs and symptoms had totally resolved. The patient ultimately had the tumor localized by contrast magnetic resonance imaging scan, demonstrating a pheochromocytoma adjacent to the right kidney. The patient had the tumor electively resected at a later date without incident.
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Discussion
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In a case report with a similar presentation to ours, an unrecognized pheochromocytoma resulted in fatality for a 28-year-old patient with symptoms of headache, epigastric discomfort, and nausea and vomiting (3). In 1951, a series of 125 pheochromocytoma resections reported 33 patient deaths (4). In 2000, a similar series of 143 pheochromocytoma resections resulted in an overall complication rate of 32% but no perioperative deaths (5). This dramatic improvement in patient outcomes can be attributed to robust preoperative imaging, appropriate preoperative medical control of hypertension, and improved surgical and anesthetic technique (2). Surgery in the patient with unsuspected pheochromocytoma presents a different anesthetic challenge. Specifically, patients who are not pretreated with 
-adrenergic blockers have more adverse intraoperative events (6). Plouin et al. (7) found significant complications to be directly related to preoperative increase in systolic blood pressure.
Nonoperative management of acute appendicitis has been described since 1959 (8) and was validated by a randomized controlled trial in 1995 (9). However, 16%–35% of patients treated with antibiotics alone will subsequently require appendectomy later (8,9). In conclusion, we describe a case of acute appendicitis in which surgery was cancelled in the operating room because of a suspected pheochromocytoma. The potential morbidity and mortality associated with surgery in a patient with an undiagnosed pheochromocytoma outweighed the risk of nonoperative management of appendicitis. The clinical risk-benefit decision in this case resulted in the resolution of the appendicitis and an unremarkable recovery after appropriate treatment for hypertension was administered.
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Footnotes
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The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Reprints will not be available from the author.
Accepted for publication August 16, 2005.
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References
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- Prys-Roberts C. Phaeochromocytoma–recent progress in its management.Br J Anaesth 2000;85:44–57.[Free Full Text]
- Schiff RL, Welsh GA. Perioperative evaluation and management of the patient with endocrine dysfunction. Med Clin N Am 2003; 87:175–92.[ISI][Medline]
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- Welbourn RB. Early surgical history of phaeochromocytoma. Br J Surg 1987;74:594–6.[ISI][Medline]
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- Stenstrom G, Haljamae H, Tisell LE. Influence of pre-operative treatment with phenoxybenzamine on the incidence of adverse cardiovascular reactions during anaesthesia and surgery for phaeochromocytoma. Acta Anaesthesiol Scand 1985;29:797–803.[ISI][Medline]
- Plouin PF, Duclos JM, Soppelsa F. Factors associated with perioperative morbidity and mortality in patients with pheochromocytoma: analysis of 165 operations at a single center. J Clin Endocrinol Metab 2001;86:1480–6.[Abstract/Free Full Text]
- Coldrey E. Five years conservative treatment of acute appendicitis. J Int Coll Surg 1959;32:255–61.
- Eriksson S, Granstrom L. Randomized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995;82:166–9.[ISI][Medline]
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Abstract
Introduction
