65-year-old patient with a personal history of alcoholism and chronic alcoholic liver disease. He underwent surgery in January 2008 for stenosing adenocarcinoma of the sigma, performing a subtotal colectomy and terminal ileostomy in the right iliac fossa. Eight months later, reconstruction of the intestinal transit with end-to-end anastomosis and closure of the ileostomy was performed. Shortly afterwards (November 2008) the patient was admitted for faecaloid peritonitis, and a resection of 1.5 metres of small intestine was performed, leaving a definitive terminal ileostomy with a rectal stump left in the pelvis, with no possibility of subsequent reconstruction.
Two months after the second operation (January 2009) the patient was admitted to hospital again due to acute renal failure and secondary hydroelectrolytic alterations, together with ileostomy debit greater than 1500 ml/day. At that time he was being treated with Tramadol, Paracetamol, oral iron and a loop diuretic (Furosemide) due to the presence of oedema in the lower limbs.
Subsequently, he returned to the hospital on several occasions and was treated in the emergency department, with renal failure and dehydration, together with water and electrolyte disorders, which were resolved in the department itself and did not require hospital admission.
In July 2009, she returned to the emergency department due to worsening general condition, with significant asthenia, prostration, difficulty in ambulation and oliguria. Laboratory tests performed in the ED showed: Creatinine: 4 mg/dl (LN 0.6-1.40); Sodium: 113 meq (LN 135-145), Potassium: 6.7 mEq/l (LN 3.5-5), Albumin: 3.1 g/dl (LN 3.4-4); Plasma calcium: 6.7 mg/dl (LN 8.5-10.5); Calcium corrected with albumin: 7.4 mg/dl; Magnesium: 0.5 mg/dl (LN 1.5-10.5); Calcium corrected with albumin: 7.4 mg/dl; Magnesium: 0. 5 mg/dl (LN 1.7-2.5); Phosphate: 2.8 mg/dl (LN 2.5-4.5); Venous pH: 7.17 (LN 7.33-7.43); Bicarbonate: 18 mmol/l (LN 22-28); The patient was admitted to Internal Medicine for acute renal failure with hyperlactacidemic metabolic acidosis and electrolyte disturbances secondary to ileostomy losses and diuretic treatment. After several days of parenteral rehydration he was discharged. The diuretic was then discontinued and treatment was started with oral rehydration salts, Loperamide (2 mg/8 hours) and magnesium salts (Magnesium Lactate: 500 mg per tablet = 2 mmol = 4 meq of Mg element) at a dose of 8 meq/8 hours/vo).
One week later, the patient suffered syncope at home with a fall to the floor and mild craniocerebral trauma to the right frontal region. On arrival at the emergency department, he had two convulsive episodes of tonic-clonic seizures that subsided with iv diazepam. A few minutes later he suffered a third seizure, for which reason treatment was started with IV phenytoin and he was admitted to the Intensive Care Unit (ICU).
A cranial CT scan was performed showing minimal subarachnoid haemorrhage in the left suprasylvian region secondary to the CT scan. ECG and chest X-ray with no significant alterations.
Laboratory tests showed ionic Ca: 2.3 mg/dl (LN 3.9-5.2); 25-hydroxyvitamin D: 10 ng/ml (LN 11-40), Magnesium 0.5 mg/dl; Sodium 125 meq, Potassium 2.8 meq. IV treatment was started with serum therapy for rehydration, as well as IV treatment with magnesium sulphate, calcium gluconate and potassium chloride to correct the electrolyte deficits. During his stay in the ICU he did not present new episodes of seizures or neurological focality, and on discharge from this department his magnesium, calcium and potassium levels had normalised. A referral to the Nutrition Unit was then requested and the physical examination revealed a weight of 63 kg (usual weight one year earlier: 74 kg), height 1.68 m; BMI 22.3 kg/m2, together with signs of a decrease in lean mass and fat mass.
During the 3 weeks that the patient was hospitalised, he was treated with dietary measures such as: astringent diet, low in fat and simple sugars, 30 minutes rest after meals, fluid intake outside meals. In addition, treatment was started with oral rehydration salts (Sueroral®), Loperamide (14 mg/day), Codeine (90 mg/day), oral magnesium supplements (up to 60 meq/day, divided into 4 intakes), calcium carbonate (500 mg) + Cholecalciferol (400 IU) every 8 hours.
The Ileostomy debit was 1500-2000 ml/day at baseline and 800-1000 ml/day at discharge. Her nutritional status improved with normalisation of nutritional parameters: cholesterol, albumin, Prealbumin and Retinol Binding Protein. Weight decreased from 63 to 61 kg, and malleolar and pretibial oedema disappeared.
At discharge, Mg levels were below normal, although relatively "safe" (Mg 1.3); with magnesiuria of 14.7 (LN 50-150), sodium, potassium, total calcium, ionic calcium and chlorine within normal range. In the last days of admission, it was decided to change the Cholecalciferol for Calcitriol (0.25 micrograms/day), in order to favour and improve magnesium absorption, maintaining the doses of oral calcium (1500 mg/day). PTH levels at discharge were normalised (38pg/ml), as were vitamin D levels (20ng/ml).
The patient is currently undergoing check-ups at the Nutrition Clinic, presenting good general condition, ileostomy debits of 1000 + 200 ml/day; with Mg levels within normal range (1.9 mg/dl), as well as the rest of the electrolytes, having been able to progressively reduce the doses of magnesium lactate to 9 comp/day (36 meq/day of elemental Mg) and the doses of calcitriol to 0.25 μg/48 hours.