Carcinoid Syndrome متلازمة الكارسينوئيد
INSTRUCTION Look at this patient who was told by her GP that she has a 'nervous bowel'. SALIENT FEATURES History · Confirm a history of chronic intermittent diarrhoea. · Flushing attacks, which may be associated with increased lacrimation and periorbital oedema. Flushing may be provoked by eating, exertion, excitement or ethanol. · Wheeze (due to bronchoconstriction during flushing attacks). Examination · Flushed face ('fire-engine' face). · Telangiectasia. Proceed as follows: · Listen to the chest for wheeze (bronchial carcinoid). · Listen to the heart (right-sided murmurs in intestinal, gastric, hepatic and ovarian carcinoid, left-sided murmurs in bronchial carcinoid). · Look for hepatomegaly (nodular and firm due to metastases, may be pulsatile due to tricuspid regurgitation). DIAGNOSIS This patient has facial flushing and tricuspid regurgitation (lesion) due to carcinoid syndrome (aetiology) and is in cardiac failure (functional status). Classic reference: Am J Med 1956; 20- 520-32. ADVANCED-LEVEL QUESTIONS What are the cardiac lesions seen in metastatic carcinoid from the liver? * Right-sided valvular lesions, including tricuspid stenosis or regurgitation, and pulmonary stenosis or regurgitation. (Note: bronchial carcinoids metastasize to the left side of the heart.) · Endocardial fibrosis. How is the diagnosis confirmed? Raised urinary levels of 5-HIAA (hydroxyindoleacetic acid). How are these tumours treated? · Emergency treatment includes prednisolone. . Severe diarrhoea: hydration, diphenoxylate with atropine, cyproheptadine or methysergide. . Octreotide (a somatostatin analogue) is associated with a significant reduction in 5-HIAA concentration. * Surgery is useful for localized carcinoid. · Chemotherapy in advanced disease (fluorouracil, streptozocin, dacarbazine). · Interferon-c~ may be useful in those who do not respond to surgery and octreotide treatment (Digestion 1994; 55 (suppl 3): 64-9).Carcinoid Syndrome