What is the best management approach for a patient with adrenal insufficiency, presenting with obstructive ileitis and electrolyte imbalance, who is experiencing persistent vomiting?

Management of Obstructive Ileitis with Electrolyte Imbalance in Adrenal Insufficiency

Immediately administer hydrocortisone 100 mg IV bolus and initiate aggressive fluid resuscitation with 0.9% isotonic saline at 1 liter over the first hour, as persistent vomiting in a patient with adrenal insufficiency represents an impending or established adrenal crisis that requires emergency treatment without delay. 1

Immediate Emergency Management

The combination of obstructive ileitis, persistent vomiting, and electrolyte imbalance in a patient with adrenal insufficiency constitutes a medical emergency requiring immediate intervention:

First-Line Treatment (Do Not Delay)

• Administer hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—this dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide the necessary mineralocorticoid effect during crisis 1, 2

• Start aggressive fluid resuscitation with 0.9% isotonic saline at 1 liter over the first hour, as dehydration and volume depletion are key pathophysiologic features 1

• Draw blood for cortisol, ACTH, electrolytes, creatinine, urea, and glucose before treatment begins, but never delay therapy waiting for results 1

Critical Clinical Context

Persistent vomiting is particularly dangerous in adrenal insufficiency because patients cannot absorb their oral glucocorticoid medication when they need it most 3. The gastrointestinal illness with vomiting represents the most common trigger for adrenal crisis 1.

Ongoing Management During Persistent Vomiting

Continuous Glucocorticoid Therapy

• Continue hydrocortisone 200 mg per 24 hours as continuous IV infusion while the patient remains unable to tolerate oral medications 1

• Alternative regimen: hydrocortisone 50 mg IV or IM every 6 hours (total 200 mg/24 hours) 1

• Do not add separate mineralocorticoid (fludrocortisone) during acute crisis, as high-dose hydrocortisone (≥50 mg per day) provides adequate mineralocorticoid activity 1, 2

Fluid Management

• Maintain slower isotonic saline infusion for the following 24-48 hours with frequent hemodynamic monitoring to avoid fluid overload 1

• Administer 3-4 liters total of isotonic saline or 5% dextrose in isotonic saline over 24 hours, adjusting based on hemodynamic response 1

Electrolyte Management and Monitoring

Expected Laboratory Abnormalities

The electrolyte imbalance in adrenal crisis typically presents with:

• Hyponatremia (present in approximately 90% of cases), though its absence should not prevent treatment if clinical suspicion is high 1

• Hyperkalemia (found in approximately 50% of patients), and its absence does not exclude adrenal crisis 1

• Increased creatinine and BUN due to prerenal renal failure from volume depletion 1, 2

Monitoring Strategy

• Monitor serum electrolytes frequently to guide fluid management and avoid complications 1

• Check blood pressure in both supine and standing (or sitting) positions for early detection of orthostatic hypotension, which occurs before supine hypotension develops 3, 1

Management of Obstructive Ileitis Component

Surgical Considerations

• Patients with adrenal insufficiency who develop complications requiring surgery should be managed in the critical care environment 3

• Continue stress-dose hydrocortisone throughout any surgical intervention without reduction 3

• Steroid supplementation should not be reduced or withdrawn while the patient has ongoing physiological stress from the obstructive process 3

Gastrointestinal Support

• Maintain NPO status with nasogastric decompression as clinically indicated for the obstruction

• Address the underlying cause of the obstructive ileitis while maintaining adequate glucocorticoid coverage

Transition to Oral Therapy

Timing of Transition

• Resume oral hydrocortisone only when the patient can reliably tolerate oral medications and the precipitating illness (obstructive ileitis) has resolved 1

• Double the usual oral hydrocortisone dose for 48 hours after resuming oral intake following uncomplicated recovery 1

Mineralocorticoid Resumption

• Restart fludrocortisone when hydrocortisone dose falls below 50 mg per day, as lower doses no longer provide adequate mineralocorticoid effect 1, 2

• Typical fludrocortisone dose is 50-200 μg once daily in the morning 2, 4

Critical Pitfalls to Avoid

• Never postpone treatment to obtain diagnostic confirmation when adrenal crisis is clinically suspected, as mortality increases with delayed intervention 1

• Never assume the patient is adequately educated about sick day rules—documented instances exist where patients are discharged with little or no education 3

• Do not attribute persistent pyrexia solely to postoperative sepsis or infection—it may be due to adrenal insufficiency itself, and steroid supplementation should not be reduced while the patient is febrile 3

• Volume-resistant hypotension is a late or even agonal event—remain vigilant for earlier symptoms including non-specific malaise, somnolence, obtunded conscious level, and cognitive dysfunction 3

Additional Supportive Care

• Consider ICU or high-dependency unit admission for severe cases with persistent hypotension or end-organ dysfunction 1

• Provide prophylaxis for gastric stress ulcers 1

• Consider low-dose heparin depending on severity of intercurrent illness 1

• Treat any precipitating infections with appropriate antimicrobial therapy 1

• Arrange early endocrinology consultation for ongoing management and education on emergency injectables 1