Refeeding syndrome (RS) is a life-threatening condition first described in severe malnourished prisoners of the Second World War1. This syndrome is defined as electrolyte and fluid shifts associated with metabolic abnormalities developed during nutritional support. RS hallmark is hypophosphatemia, but also includes hypomagnesemia, hypokalemia, vitamin deficiencies, abnormal glucose metabolism and fluid retention. Prolonged fasting is the most important risk factor and RS may be precipitated by oral, enteral or parenteral nutrition4,5.
An 82 year-old female was admitted due to recurrent vomiting during 10 days. Her past medical history included cerebrovascular disease, diabetes and hypertension. On hospital admission she was febrile, dehydrated and presented low body mass index (20.8 kg/m2). Initial evaluation revealed acute kidney injury (creatinine 4.1 mg/dl), hypokalaemia (K+ 3.2 mg/dl), hyperphosphatemia (Pi 5.4 mg/dl) and normal serum sodium and magnesium. Fluid and electrolyte replacement were immediately started but vomiting persisted. Nasogastric intubation revealed stasis (1800 cc/24h). Upper gastrointestinal endoscopy detected lumen narrowing in second/third duodenum parts. CT scan identified a heterogeneous mass in the pancreatic head causing Wirsung duct dilation and duodenal compression (Figure 1). Surgical resection was ruled out considering the advanced age and poor performance status. Palliative care with gastroduodenal self-expandable metallic stent (SEMS) placement was scheduled.
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