Milk alkali syndrome - Burnett's syndrome - Calcium alkali syndrome

Apr 2014   › › Milk alkali ((Burnett's) syndrome - causes, symptoms and treatment
Milk alkali syndrome (MAS) also known as Burnett's syndrome is actually calcium alkali disorder caused by repeated overdose of calcium along with absorbable alkali.
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The syndrome was first described by Charles Hoyt Burnett (1913–1967), an American physician. Initial symptoms of milk alkali syndrome include nausea, vomiting, high urine output followed by volume depletion and alkalosis. The treatment regimen includes volume restoration with intravenous infusion of normal saline and discontinuance of calcium and vitamin D supplements. Left untreated, it can lead to soft tissue calcification and permanent kidney damage.

What is milk-alkali syndrome?

In 1915, Bertram Welton Sippy (1866-1924), an American physician, introduced "Sippy regimen" for the treatment and management of peptic ulcers. The patients were advised hourly ingestion of milk and cream. Gradually eggs and cereals were added to the diet of milk and cream. Alkali powders, which were absorbable, were also given for the relief of peptic ulcer symptoms.

    • Later on, many peptic ulcer patients undergoing the Sippy regimen were found to develop hypercalcemia, alkalosis and renal failure. The discontinuance of the regimen resulted in the reversal of these adverse symptoms. As milk alkali syndrome is associated with taking large quantities of milk and absorbable alkali, it had come to be known as milk alkali syndrome. As milk alkali syndrome was first described by Charles Hoyt Burnett, it was also called Burnett's syndrome in his honor.

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    • The advent of histamine-2 blockers and proton pump inhibitors and eradication of causative Helicobacter pylori bacteria with antibiotics, has lead to drastic change in the peptic ulcer treatment approach. The incidence of this classic Burnett's syndrome had decreased drastically.

    Now there is increasing awareness about osteoporosis. There is also increase in self medication of calcium carbonate formulations for treating osteoporosis, hyperacidity and gastroesophageal reflux disease (GERD). This trend has contributed to the increase in the current version of milk alkali syndrome. Several cases with symptoms of hypercalcemia, metabolic alkalosis and renal failure are being reported. Medical investigations reveal that the common cause is the excessive use of over the counter supplements and antacids containing calcium carbonate.

    How is Burnett's syndrome caused?

    The excessive ingestion of calcium, milk and absorbable alkaline compounds has been the main triggering factor for developing the Burnett's syndrome. Excess calcium causes hypercalcemia and alkali ingestion causes alkalosis. Due to alkalosis there is reduced glomerular filtration rate (GFR) and increase in tubular reabsorption of calcium. Hypercalcemia, by inducing renal vasoconstriction reduces glomerular filtration rate. This leads to reduction of extracellular volume, reduction in renal excretion of calcium and its retention in the body.

    Once the Burnett's syndrome develops, it contributes to its own maintenance because of volume depletion from increased sodium and water excretion and increase in tubular reabsorption of calcium.

    Milk alkali syndrome symptoms

    Considering the severity of symptoms, Burnett's syndrome is categorized into subacute, acute and chronic forms. The symptoms of Burnett's syndrome include:
    • lack of appetite,
    • nausea,
    • vomiting,
    • headache,
    • constipation,
    • abdominal pain,
    • back pain,
    • weakness,
    • fatigue,
    • drowsiness,
    • depression,
    • symptoms of altered mental status,
    • malaise,
    • symptom of confusion,
    • dry oral mucosa,
    • poor skin turgor,
    • symptoms of hypercalcemia,
    • symptoms of metabolic alkalosis and renal failure.
    The symptoms of chronic form of the Burnett's syndrome include myalgia, tremor, polyuria, polydipsia, soft tissue calcification, nephrocalcinosis and irreversible renal failure.

    Milk-alkali syndrome treatment

    The first line of treatment is volume restoration with intravenous normal saline to improve renal function and facilitate calcium and bicarbonate excretion. All the supplements containing calcium and vitamin D should be discontinued. Milk intake the patients may be reduced. The intravenous hydration and furosemide (a loop diuretic) medication usually reverses hypercalcemia and alkalosis. Early recognition of symptoms, diagnosis and treatment can help in the recovery and normalization of renal function.

    During the course of treatment, transitional hypocalcemia may result, which may be treated by judicial administration of calcium supplements.

    Susceptibility to Burnett's syndrome

    The elderly people have a lower glomerular filtration rate in the kidneys, decreased calcium clearance and reduced skeletal buffering of calcium. They are highly susceptible.
    Any form of dehydrating debility or chronic dehydration can predispose a person to calcium-alkali syndrome.
    Patients suffering from anorexia nervosa or bulimia nervosa are particularly susceptible due to their erratic food habits.
    Patients who have preexisting renal impairment or failure are highly susceptible.
    Women suffering from excessive vomiting during pregnancy (hyperemesis gravidarum) are vulnerable.
    In pregnant women calcium is absorbed at a higher rate from the GI tract. They are also advised to take more milk. Gastric reflux is a common problem with them and taking over-the-counter antacids containing an abosorbable base may predispose them to the Burnett's syndrome.
    Postmenopausal women and transplant patients taking high doses of calcium supplements and vitamin D to treat or prevent osteoporosis are also susceptible develop milk-alkali syndrome.
    The use of thiazide diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensin receptor blockers or angiotensin-converting-enzyme inhibitor can predispose a person to milk alkali syndrome.
    Betal nut chewers in Asia usually blend the nuts with oyster shell lime paste. This habit increases the ingestion of alkaline calcium many folds.

    If such susceptible patients are to be given mineral supplements, care must be taken not to include any alkaline forms of trace minerals. They should not also be given excess milk. There is a great need to educate the patients on proper use and dosing of all non prescription medicines and supplements to prevent syndromes like Burnett's arising out of inappropriate medication.

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    References:
    1.Altun E, Kaya B, Paydas S, Balal M. Milk alkali syndrome induced by calcitriol and calcium bicarbonate in a patient with hypoparathyroidism. Indian J Endocr Metab 2013;17:191-3
    2.Almusawi A, Alhawaj S, Al-Mousawi M, Dashti T. No more milk in milk-alkali syndrome: a case report. Oman Med J. 2012 Sep;27(5):413-4.
    3.Michelle V Gordon, P Shane Hamblin and Lawrence P McMahon. Life-threatening milk-alkali syndrome resulting from antacid ingestion during pregnancy. Med J Aust 2005; 182 (7): 350-351.

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