Huisman I A, Stegeman C A, de Jong P E, Gansevoort R T
Afd. Algemene Interne Geneeskunde, Academisch Ziekenhuis, Postbus 30.001, 9700 RB Groningen.
Ned Tijdschr Geneeskd. 2003 Mar 22;147(12):551-5.
A 39-year-old woman had been investigated elsewhere due to symptomatic hypokalaemia, renal potassium wasting and metabolic alkalosis. Vomiting was considered to be the underlying cause but the patient repeatedly denied this behaviour. After extensive investigations, Bartter's syndrome was finally diagnosed. Eighteen months later the patient was readmitted due to progressive renal insufficiency. On the basis of a very low urinary chloride excretion and the aforementioned laboratory results, it was concluded that the metabolic disturbances were due to vomiting and the diagnosis of Bartter's syndrome was rejected. Upon being confronted with these findings, the patient finally admitted to vomiting, but stated that this happened involuntarily after meals. She had a stenotic ulcer in the pylorus and a gastric biopsy demonstrated the presence of Helicobacter pylori associated gastritis. Eradication therapy was given and the symptoms disappeared. The renal insufficiency was partly accounted for by hypovolaemia and partly by tubulointerstitial nephropathy (demonstrated by kidney biopsy) which was probably due to the chronic hypokalaemia. This case illustrates the difficulty of establishing the differential diagnosis of hypokalaemia, especially in the case of denied vomiting. However, it also shows that in such cases the correct diagnosis can be made if objective parameters are used.
一名39岁女性因症状性低钾血症、肾性钾丢失和代谢性碱中毒在其他地方接受了检查。呕吐被认为是潜在病因，但患者反复否认有此行为。经过广泛检查，最终诊断为巴特综合征。18个月后，患者因进行性肾功能不全再次入院。基于极低的尿氯排泄量和上述实验室检查结果，得出代谢紊乱是由呕吐引起的结论，巴特综合征的诊断被否定。面对这些检查结果，患者最终承认有呕吐行为，但称这是饭后不由自主发生的。她的幽门有一个狭窄性溃疡，胃活检显示存在幽门螺杆菌相关性胃炎。给予根除治疗后症状消失。肾功能不全部分归因于血容量不足，部分归因于肾小管间质性肾病（经肾活检证实），这可能是由慢性低钾血症所致。该病例说明了低钾血症鉴别诊断的困难，尤其是在否认呕吐的情况下。然而，它也表明，在这种情况下，如果使用客观参数，就可以做出正确诊断。
