Jones Annabel S, Warren Annabelle M, Bach Leon A, Sztal-Mazer Shoshana
Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, Australia.
Department of Medicine (Alfred), Monash University, Melbourne, Australia.
Endocrinol Diabetes Metab Case Rep. 2020 Oct 6;2020. doi: 10.1530/EDM-20-0103.
Conventional treatment of hypoparathyroidism relies on oral calcium and calcitriol. Challenges in managing post-parathyroid- and post-thyroidectomy hypocalcaemia in patients with a history of bariatric surgery and malabsorption have been described, but postoperative management of bariatric surgery in patients with established hypoparathyroidism has not. We report the case of a 46-year-old woman who underwent elective sleeve gastrectomy on a background of post-surgical hypoparathyroidism and hypothyroidism. Multiple gastric perforations necessitated an emergency Roux-en-Y gastric bypass. She was transferred to a tertiary ICU and remained nil orally for 4 days, whereupon her ionised calcium level was 0.78 mmol/L (1.11-1.28 mmol/L). Continuous intravenous calcium infusion was required. She remained nil orally for 6 months due to abdominal sepsis and the need for multiple debridements. Intravenous calcium gluconate 4.4 mmol 8 hourly was continued and intravenous calcitriol twice weekly was added. Euthyroidism was achieved with intravenous levothyroxine. Maintaining normocalcaemia was fraught with difficulties in a patient with pre-existing surgical hypoparathyroidism, where oral replacement was impossible. The challenges in managing hypoparathyroidism in the setting of impaired enteral absorption are discussed with analysis of the cost and availability of parenteral treatments.
Management of hypoparathyroidism is complicated when gastrointestinal absorption is impaired. Careful consideration should be given before bariatric surgery in patients with pre-existing hypoparathyroidism, due to potential difficulty in managing hypocalcaemia, which is exacerbated when complications occur. While oral treatment of hypoparathyroidism is cheap and relatively simple, available parenteral options can carry significant cost and necessitate a more complicated dosing schedule. International guidelines for the management of hypoparathyroidism recommend the use of PTH analogues where large doses of calcium and calcitriol are required, including in gastrointestinal disorders with malabsorption. Approval of subcutaneous recombinant PTH for hypoparathyroidism in Australia will alter future management.
甲状旁腺功能减退症的传统治疗依赖口服钙剂和骨化三醇。已有文献描述了有减肥手术和吸收不良病史的患者在甲状旁腺切除术后和甲状腺切除术后低钙血症管理方面的挑战，但对于已确诊甲状旁腺功能减退症患者的减肥手术术后管理尚未见报道。我们报告了一例46岁女性患者，该患者在术后甲状旁腺功能减退症和甲状腺功能减退症背景下接受了择期袖状胃切除术。多处胃穿孔需要急诊行Roux-en-Y胃旁路术。她被转入三级重症监护病房，4天内禁食，此时其离子钙水平为0.78 mmol/L（参考范围1.11 - 1.28 mmol/L）。需要持续静脉输注钙剂。由于腹部感染和需要多次清创，她6个月内一直禁食。持续每8小时静脉输注葡萄糖酸钙4.4 mmol，并每周添加两次静脉骨化三醇。通过静脉注射左甲状腺素实现了甲状腺功能正常。对于既往有手术性甲状旁腺功能减退症且无法口服补充的患者，维持血钙正常充满困难。本文结合肠内吸收受损情况下甲状旁腺功能减退症管理的挑战，分析了肠外治疗的成本和可及性。
当胃肠道吸收受损时，甲状旁腺功能减退症的管理会变得复杂。对于已有甲状旁腺功能减退症的患者，在进行减肥手术前应仔细考虑，因为管理低钙血症可能存在潜在困难，并发症发生时会更加严重。虽然甲状旁腺功能减退症的口服治疗便宜且相对简单，但可用的肠外治疗方案可能成本高昂且给药方案更复杂。甲状旁腺功能减退症管理的国际指南建议，在需要大剂量钙剂和骨化三醇时，包括在伴有吸收不良的胃肠道疾病中，使用甲状旁腺激素类似物。澳大利亚皮下重组甲状旁腺激素用于甲状旁腺功能减退症的获批将改变未来的管理方式。
